Provider Demographics
NPI:1548833452
Name:PURE HEALTH MEDICINE LLC
Entity type:Organization
Organization Name:PURE HEALTH MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:DECONTEE
Authorized Official - Last Name:KPANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-523-3663
Mailing Address - Street 1:3966 JEFFERSON TOWNSHIP PKWY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-1704
Mailing Address - Country:US
Mailing Address - Phone:678-523-3663
Mailing Address - Fax:
Practice Address - Street 1:905 SADDLE HL
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4915
Practice Address - Country:US
Practice Address - Phone:678-842-8835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty